Vascular catastrophes following pancreas transplantation: an evolution in strategy at a single center

Fridell, Jonathan A.; Johnson, Matthew S.; Goggins, William C.; Beduschi, Thiago; Mujtaba, Muhammad A.; Goble, Michelle L.; Powelson, John A.

doi:10.1111/j.1399-0012.2011.01560.x

Cited by 41 publications

(34 citation statements)

References 35 publications

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“…For severe gastrointestinal bleeding that occurs more than one week post-transplant, however, one must not assume it is secondary to anastomotic bleeding. In this setting, it is imperative to rule out a leaking pseudoaneurysm, which is best diagnosed and treated with angiographic techniques [124] . When using the retroperitoneal approach to the SMV for portal-enteric drainage, in order to perform an anastomosis to the small bowel, one must make a window in the mesentery of the right colon.…”

Section: El-hennawy H Et Al Exocrine Drainage In Pancreas Transplantsmentioning

confidence: 99%

Exocrine drainage in vascularized pancreas transplantation in the new millennium

El‐Hennawy¹,

Stratta²,

Smith³

2016

WJT

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The history of vascularized pancreas transplantation largely parallels developments in immunosuppression and technical refinements in transplant surgery. From the late-1980s to 1995, most pancreas transplants were whole organ pancreatic grafts with insulin delivery to the iliac vein and diversion of the pancreatic ductal secretions to the urinary bladder (systemic-bladder technique). The advent of bladder drainage revolutionized the safety and improved the success of pancreas transplantation. However, starting in 1995, a seismic change occurred from bladder to bowel exocrine drainage coincident with improvements in immunosuppression, preservation techniques, diagnostic monitoring, general medical care, and the success and frequency of enteric conversion. In the new millennium, pancreas transplants are performed predominantly as pancreatico-duodenal grafts with enteric diversion of the pancreatic ductal secretions coupled with iliac vein provision of insulin (systemic-enteric technique) although the systemic-bladder technique endures as a preferred alternative in selected cases. In the early 1990s, a novel technique of venous drainage into the superior mesenteric vein combined with bowel exocrine diversion (portal-enteric technique) was designed and subsequently refined over the next ≥ 20 years to recreate the natural physiology of the pancreas with firstpass hepatic processing of insulin. Enteric drainage usually refers to jejunal or ileal diversion of the exocrine secretions either with a primary enteric anastomosis or with an additional Roux limb. The portal-enteric technique has spawned a number of newer and revisited techniques of enteric exocrine drainage including duodenal or gastric diversion. Reports in the literature suggest no differences in pancreas transplant outcomes irrespective of type of either venous or exocrine diversion. The purpose of this review is to examine the FIELD OF VISION

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Section: El-hennawy H Et Al Exocrine Drainage In Pancreas Transplantsmentioning

confidence: 99%

Exocrine drainage in vascularized pancreas transplantation in the new millennium

El‐Hennawy¹,

Stratta²,

Smith³

2016

WJT

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“…Among the most devastating and potentially graft- and life-threatening complications in pancreas transplantation are those involving the arterial vascular anastomosis [8]. Vascular issues may be the most challenging clinically [9].…”

Section: Discussionmentioning

confidence: 99%

“…The incidence has been reported around 1.4%, with individual reports of arterial PAs and mycotic aneurysms [8]. It is often difficult to detect formation of pseudoaneurysm and/or arterioenteric fistula before developing significant hemorrhage [6,16,17].…”

Section: Discussionmentioning

confidence: 99%

Arterial Pseudoaneurysm Associated with Pancreas and Kidney Transplantation: A Case Report

et al. 2017

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Patient: Male, 49Final Diagnosis: Arterial pseudoaneurysmSymptoms: Abdominal pain • fever and a pulsatile tumor located in the right iliac fossaMedication: —Clinical Procedure: Endovascular and surgical approachSpecialty: TransplantologyObjective:Unusual clinical courseBackground:Pseudoaneurysm is a rare vascular complication in pancreas transplantation. This complication develops from a disruption of the arterial continuity, usually related to trauma, infection, vasculitis, or complications in vascular procedures.Case Report:A 43-year-old man underwent simultaneous pancreas and kidney transplantation for end-stage renal disease. He subsequently developed acute pancreatitis and acute kidney cellular rejection as late complications, thus returning to hemodialysis. A new, uneventful kidney transplantectomy and living donor kidney transplant was performed. One year after the last transplant, the patient presented with moderate abdominal pain, fever, and a pulsatile tumor located in the right iliac fossa. A pseudoaneurysm located in the pancreatic Y graft was observed. The patient was treated using an endovascular and surgical approach.Conclusions:A combined procedure using an endovascular and surgical approach promoted a good vascular control with a lower risk of bleeding in a rare case of pseudoaneurysm in a transplant patient.

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“…A literature review is summarized in Table , showing the reported clinical presentations, pathogen isolates, treatment, and graft and patient survival . Severe bleeding is, unfortunately, not uncommon, and is accompanied by allograft loss in virtually all cases, with a high mortality rate . The absence of systemic inflammatory response syndrome may not exclude the infectious origin of PAs.…”

Section: Discussionmentioning

confidence: 99%

“…Nevertheless, we firmly believe that utilizing a prosthetic material in an infected field should be avoided as far as possible, especially in patients taking immunosuppressants. Use of prosthetic grafts or endovascular stents for the treatment of mycotic PAs exposes patients to an increased risk of persistent infection and PA recurrence, potentially leading to anastomotic leakage . On the other hand, temporary placement of a stent graft allows management of the PA origin before surgical exploration, facilitating vascular control and definitive repair.…”

Section: Discussionmentioning

confidence: 99%

Presentation and management of mycotic pseudoaneurysm after kidney transplantation

Patrono

Verhelst

Buemi

et al. 2015

Transplant Infectious Dis

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Pseudoaneurysms (PAs) developing at the site of vascular anastomosis after organ transplantation are a rare but serious complication. We report a series of 3 cases of PA observed in a single center over a period of 18 years. The mode of presentation was acute bleeding in 2 cases. In the third patient, who underwent combined kidney and pancreas transplantation, the PA on the renal graft was discovered by chance. Graft removal associated with iliac artery ligation and extra-anatomic femoro-femoral bypass represents the standard treatment. However, interposition of a venous homograft may allow preservation of inferior limb perfusion and possibly graft salvage.

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Vascular catastrophes following pancreas transplantation: an evolution in strategy at a single center

Abstract: Vascular catastrophes such as PA and AEF are potentially life-threatening complications of pancreas transplantation. Immediate treatment at the time of bleeding is essential and covered stenting of the involved artery may provide immediate vascular control in these situations.

Cited by 41 publications

References 35 publications

Exocrine drainage in vascularized pancreas transplantation in the new millennium

Exocrine drainage in vascularized pancreas transplantation in the new millennium

Arterial Pseudoaneurysm Associated with Pancreas and Kidney Transplantation: A Case Report

Presentation and management of mycotic pseudoaneurysm after kidney transplantation

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